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Specific Phobia
DSM-III In DSM-III, this disorder is called Simple Phobia Diagnostic Criteria A'''. A persistent, irrational fear of, and compelling desire to avoid, an object or a situation other than being alone, or in public places away from home (Agoraphobia), or of humiliation or embarrassment in certain social situations (Social Phobia). Phobic objects are often animals, and phobic situations frequently involve heights or closed spaces. '''B. Significant distress from the disturbance and recognition by the individual that his or her fear is excessive or unreasonable. C'''. Not due to another mental disorder, such as Schizophrenia or Obsessive Compulsive Disorder. '''Differential Diagnosis Schizophrenia and Obsessive Compulsive Disorder In Schizophrenia certain activities may be avoided in response to delusions. Similarly, in Obsessive Compulsive Disorder phobic avoidance of certain situations that are associated with anxiety about dirt or contamination is frequent. The diagnosis of Simple Phobia should not be made in either case. DSM-IV Diagnostic Criteria A'''. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). '''B. Exposure to the stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging. C'''. The person recognizes that the fear is excessive or unreasonable. '''Note: In children, this feature may be absent. D'''. The phobic situation(s) is avoided or else is endured with intense anxiety or distress. '''E. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia. F'''. In individuals under age 18 years, the duration is at least 6 months. '''G. The anxiety, Panic Attacks, or phobic avoidance associated with the specific object or situation are not better accounted for by another mental disorder, such as Obsessive-Compulsive Disorder (e.g., fear of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), Separation Anxiety Disorder (e.g., avoidance of school), Social Phobia (e.g., avoidance of social situations because of fear of embarrassment), Panic Disorder With Agoraphobia, or Agoraphobia Without History of Panic Disorder. Specify type: * Animal Type * Natural Environment Type (e.g., heights, storms, water) * Blood-Injection-Injury Type * Situational Type (e.g., airplanes, elevators, enclosed places) * Other Type (e.g., phobic avoidance of situations that may lead to choking, vomiting, or contracting an illness; in children, avoidance of loud sounds or costumed characters) Subtypes The following subtypes may be specified to indicate the focus of fear or avoidance in Specific Phobia (e.g., Specific Phobia, Animal Type). The frequency of the subtypes in adult clinical settings, from most to least frequent, is Situational; Natural Environment; Blood-Injection-Injury; and Animal. In many cases, more than one subtype of Specific Phobia is present. Having one phobia of a specific subtype tends to increase the likelihood of having another phobia from within the same subtype (e.g., fear of cats and snakes). When more than one subtype applies, they should all be noted (e.g., Specific Phobia, Animal and Natural Environment Types). Animal Type This subtype should be specified if the fear is cued by animals or insects. This subtype generally has a childhood onset. Natural Environment Type This subtype should be specified if the fear is cued by objects in the natural environment, such as storms, heights, or water. This subtype generally has a childhood onset. Blood-Injection-Injury Type This subtype should be specified if the fear is cued by seeing blood or an injury or by receiving an injection or other invasive medical procedure. This subtype is highly familial and is often characterized by a strong vasovagal response. Situational Type This subtype should be specified if the fear is cued by a specific situation such as public transportation, tunnels, bridges, elevators, flying, driving, or enclosed places. This subtype has s bimodal age-at-onset distribution, with one peak in childhood and another peak in the mid-20s. This subtype appears to be similar to Panic Disorder With Agoraphobia in its characteristic sex ratios, familial aggregation pattern, and age at onset. Other Type This subtype should be specified if the fear is cued by other stimuli. These stimuli might include the fear or avoidance of situations that might lead to choking, vomiting, or contracting an illness; "space" phobia (i.e., the individual is afraid of falling down if away from walls or other means of physical support); and children's fears of loud sounds or costumed characters. Differential Diagnosis Panic Disorder With Agoraphobia Specific Phobias differ from most other Anxiety Disorders in levels of intercurrent anxiety. Typically, individuals with Specific Phobia, unlike those with Panic Disorder With Agoraphobia, do not present with pervasive anxiety, because their fear is limited to specific, circumscribed objects or situations. However, generalized anxious anticipation may emerge under conditions in which encounters with the phobic stimulus become more likely (e.g., when a person who is fearful of snakes moves to a desert area) or when life events force immediate confrontation with the phobic stimulus (e.g., when a person who is fearful of flying is forced by circumstances to fly). Differentiation of Specific Phobia, Situational Type, from Panic Disorders With Agoraphobia may be particularly difficult because both disorders may include Panic Attacks and avoidance of similar types of situations (e.g., driving, flying, public transportation, enclosed places). Prototypically, Panic Disorder With Agoraphobia is characterized by the initial onset of unexpected Panic Attacks and the subsequent avoidance of multiple situations thought to be likely triggers of the Panic Attacks. Prototypically, Specific Phobia, Situational Type, is characterized by situational avoidance in the absence of recurrent unexpected Panic Attacks. Some presentations fall between these prototypes and require clinical judgement in the selection of the most appropriate diagnosis. Four factors can be helpful in making this judgment: the focus of fear, the type of number of Panic Attacks, the number of situations avoided, and the level of intercurrent anxiety. For example, an individual who had not previously feared or avoided elevators has a Panic Attack in an elevator and begins to dread going to work because of the need to take the elevator to his office on the 24th floor. If this individual subsequently has Panic Attacks only in elevators (even if the focus of fear is on the Panic Attack), then a diagnosis of Specific Phobia may be appropriate. If, however, the individual experiences unexpected Panic Attacks in other situations and begins to avoid or endure with dread other situations because of fear of a Panic Attack, then a diagnosis of Panic Disorder With Agoraphobia would be warranted. Furthermore, the presence of pervasive apprehension about having a Panic Attack even when not anticipating exposure to a phobic situation also supports a diagnosis of Panic Disorder With Agoraphobia. If the individual has additional unexpected Panic Attacks in other situations but no additional avoidance or endurance with dread develops, then the appropriate diagnosis would be Panic Disorder Without Agoraphobia. Concurrent diagnoses of Specific Phobia and Panic Disorder With Agoraphobia are sometimes warranted. In these cases, consideration of the focus of the individual's concern about the phobic situation may be helpful. For example, avoidance of being alone because of concern about having unexpected Panic Attacks warrants a diagnosis of Panic Disorder With Agoraphobia (if other criteria are met), whereas the additional phobic avoidance of air travel, if due to worries about bad weather conditions and crashing, may warrant an additional diagnosis of Specific Phobia. Other Anxiety Disorders Specific Phobia and Social Phobia can be differentiated on the basis of the focus of the fears. For example, avoidance of eating in a restaurant may be based on concerns about negative evaluation from others (i.e., Social Phobia) or concerns about choking (i.e., Specific Phobia). In contrast to the avoidance in Specific Phobia, the avoidance in Posttraumatic Stress Disorder follows a life-threatening stressor and is accompanied by additional features (e.g., reexperiencing the trauma and restricted affect). In Obsessive-Compulsive Disorder, the avoidance is associated with the content of the obsession (e.g., dirt, contamination). In individuals with Separation Anxiety Disorder, a diagnosis of Specific Phobia is not given if the avoidance behavior is exclusively limited to fears of separation from persons to whom the individual is attached. Moreover, children with Separation Anxiety Disorder often have associated exaggerated fears of people or events (e.g., of muggers, burglars, kidnappers, car accidents, airplane travel) that might threaten the integrity of the family. A separate diagnosis of Specific Phobia would rarely be warranted. Other mental disorders The differentiation between Hypochondriasis and a Specific Phobia, Other Type (i.e., avoidance of situations that may lead to contracting an illness), depends on the presence or absence of disease conviction. Individuals with Hypochondriasis are preoccupied with fears of having a disease, whereas individuals with a Specific Phobia fear contracting a disease (but do not believe it is already present). In individuals with Anorexia Nervosa and Bulimia Nervosa, a diagnosis of Specific Phobia is not given if the avoidance behavior is exclusively limited to avoidance of food and food-related cues. An individual with Schizophrenia or another Psychotic Disorder may avoid certain activities in response to delusions, but does not recognize that the fear is excessive or unreasonable. Normal fears Fears are very common, particularly in childhood, but they do not warrant a diagnosis of Specific Phobia unless there is significant interference with social, educational, or occupational functioning or marked distress about having the phobia. DSM-5 Diagnostic Criteria A'. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). ('Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging.) B'''. The phobic object or situation almost always provokes immediate fear or anxiety. '''C. The phobic object or situation is actively avoided or endured with intense fear or anxiety. D'''. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context. '''E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. F'''. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. '''G. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in posttraumatic stress disorder); separation from home or an attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder). Specify if: * Animal (e.g., spiders, insects, dogs). * Natural environment '''(e.g., heights, storms, water). * '''Blood-injection-injury (e.g., needles, invasive medial procedures). ** Fear of blood ** Fear of injections and transfusions ** Fear of other medical care ** Fear of injury * Situational (e.g., airplanes, elevators, enclosed places). * Other (e.g., situations that may lead to choking or vomiting; in children, e.g., loud sounds or costumed characters). Note: When more than one phobic stimulus is present, list separately all categories that apply (e.g., for fear of snakes and flying, specific phobia, animal, and specific phobia, situational). Specifiers It is common or individuals to have multiple specific phobias. The average individual with specific phobia fears three objects or situations, and approximately 75% of individuals with specific phobia fear more than one situation or object. In such cases, multiple specific phobia diagnoses, each reflecting its own phobic stimulus, would need to be given. For example, if an individual fears thunderstorms and flying, then two diagnoses would be given: specific phobia, natural environment, and specific phobia, situational. Differential Diagnosis Agoraphobia Situational specific phobia may resemble agoraphobia in its clinical presentation, given the overlap in feared situations (e.g., flying, enclosed places, elevators). If an individual fears only one of the agoraphobic situations, then specific phobia, situational, may be diagnosed. If two or more agoraphobic situations are feared, a diagnosis of agoraphobia is likely warranted. For example, an individual who fears airplanes and elevators (which overlap with the "public transportation" agoraphobic situation) but does not fear other agoraphobic situations would be diagnosed with specific phobia, situational, whereas an individual who fears airplanes, elevators and crowds (which overlap with two agoraphobic situations, "using public transportation" and "standing in line and or being in a crowd") would be diagnosed with agoraphobia. Criterion B of agoraphobia (the situations are feared or avoided "because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms") can also be useful in differentiating agoraphobia from specific phobia. If the situations are feared for other reasons, such as fear of being harmed directly by the object or situations (e.g., fear of the plane crashing, fear of the animal biting), a specific phobia diagnosis may be more appropriate. Social anxiety disorder If the situations are feared because of negative evaluation, social anxiety disorder should be diagnosed instead of specific phobia. Separation anxiety disorder If the situations are feared because of separation from a primary caregiver or attachment figure, separation anxiety disorder should be diagnosed instead of specific phobia. Panic disorder Individuals with specific phobia may experience panic attacks when confronted with their feared situation or object. A diagnosis of specific phobia would be given if the panic attacks only occurred in response to the specific object or situation, whereas a diagnosis of panic disorder would be given if the individual also experienced panic attacks that were unexpected (i.e., not in response to the specific phobia object or situation). Obsessive-compulsive disorder If an individual's primary fear or anxiety is of an object or situation as a result of obsessions (e.g., fear of blood due to obsessive thoughts about contamination from blood-borne pathogens HIV; fear of driving due to obsessive images of harming others), and if other diagnostic criteria for obsessive-compulsive disorder are met, then obsessive-compulsive disorder should be diagnosed. Trauma- and stressor-related disorders If the phobia develops following a traumatic event, posttraumatic stress disorder (PTSD) should be considered as a diagnosis. However, traumatic events can precede the onset of PTSD and specific phobia. In this case, a diagnosis of specific phobia would be assigned only if all of the criteria for PTSD are not met. Eating disorders A diagnosis of specific phobia is not given if the avoidance behavior is exclusively limited to avoidance of food and food-related cues, in which case a diagnosis of anorexia nervosa or bulimia nervosa should be considered. Schizophrenia spectrum and other psychotic disorders When the fear and avoidance are due to delusional thinking (as in schizophrenia or other schizophrenia spectrum and other psychotic disorders), a diagnosis of specific phobia is not warranted.